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This matched case-control study investigated potentially inappropriate medication (PIM) use, polypharmacy, and other potential risk factors for falls among hospitalized older adults in Taiwan.During an 18-month study period, 131 case patients who experienced a fall during hospitalization in an acute-care hospital were identified and matched by the time of day, hospital ward, and age to controls (five for each case) who were selected through random systematic sampling. Data on demographics, medical characteristics, and all orally and intravascularly administered medications during hospitalization prior to a fall were collected. PIMs were assessed using the 2019 Beers criteria.A conditional logistic regression analysis revealed that admission to the departments of internal medicine (odds ratio [OR] = 2.33; 95% confidence interval [CI] = 1.09-4.91) and neurology and rehabilitation (OR = 4.67; 95% CI = 2.08-10.5), diabetes with end-organ damage (OR = 2.07; 95% CI = 1.11-3.86), PIM use of central nervous system drugs (OR = 1.81; 95% CI = 1.15-2.86), use of colchicine (OR = 5.49; 95% CI = 1.34-22.5) and spironolactone (OR = 4.54; 95% CI = 1.31-15.8) for renal function impairment, and polypharmacy (≥5 medications; OR = 1.81; 95% CI = 1.05-3.10) significantly increased the risk of falls. By contrast, being overweight or obese (OR = 0.47; 95% CI = 0.29-0.78) was associated with a significantly lower risk of falls.PIM use may increase the risk of falls in hospitalized older patients, and PIM identification and evaluation can reduce this risk. Geriatr Gerontol Int 2022; 22: 857-864.

Objective To investigate differences between older men and women in Taiwan in personal and situational risk factors for sustaining a traumatic brain injury (TBI) versus soft-tissue injury (STI) due to a fall. Design Matched case-control study. Participants and settings Cases were defined as patients with a primary diagnosis of TBI due to a fall and were identified from those 60 years or older who visited the emergency department (ED) of 3 university-affiliated hospitals in 2015. Matched by the same hospital ED, gender, and time of falling, 3 controls who had no TBI and who had sustained only soft-tissue injury (STI) due to falling were selected for comparison with each case. Personal factors and situational exposures were compared between the control and case groups. In total, 96 cases and 288 controls in men and 72 cases and 216 controls in women participated in this study. Main measures Personal factors (sociodemographic and lifestyle factors, medical characteristics, and functional abilities) and situational exposures (location, activities before the fall, center-of-mass change, type of fall, falling direction, protective response, and impact during the fall). Results In men, after adjusting for other variables, older age (odds ratio [OR] = 1.04), regular alcohol use (OR = 2.03), an indoor fall (OR = 1.92), activity of getting in/out of bed (OR = 2.56), a fall due to dizziness (OR = 4.09), and falling backward (OR = 2.95) were independently associated with a higher odds of TBI. In women, an older age (OR = 1.03), the presence of Parkinson disease (OR = 10.4), activities of toileting (OR = 2.50), getting in/out of bed (OR = 4.90), and negotiating stairs (OR = 7.13), a fall due to dizziness (OR = 5.05), and falling backward (OR = 2.61) were independently associated with a higher odds of TBI. Conclusions Our results demonstrated similarities and differences in personal and situational risk factors for fall-related TBIs versus STIs between older men and women, and gender differences should be considered when developing intervention strategies.

Objective To compare the effects of computerized cognitive training (CCT) and tai chi (TC) with usual care (UC) on cognitive functions and secondary outcomes in older adults with traumatic brain injury. Participants and settings Ninety-six patients aged 55 years and older who had a diagnosis of traumatic brain injury requiring hospital admission. Design Randomized controlled trial. Main measures The Mattis Dementia Rating Scale (MDRS), Mini-Mental State Examination, modified Telephone Interview of Cognitive Status, and Trail Making Tests A and B. Results Compared with UC, CCT increased scores on the MDRS's total, attention, and memory and those on the Mini-Mental State Examination and Telephone Interview of Cognitive Status over the 6-month intervention; TC increased scores on the MDRS's total and conceptualization and those on the Mini-Mental State Examination over the 6-month intervention, while it also increased scores on the MDRS's total and initiation/preservation and those on the Telephone Interview of Cognitive Status and reduced the time to complete the Trail Making Test B over the 12-month study. Furthermore, compared with UC, CCT increased handgrip strength and TC reduced the time to complete 5 sit-to-stands over the 6-month intervention. Conclusion Both CCT and TC may improve global cognition and different specific cognitive domains in older traumatic brain injury patients; the TC's effect may last for at least an additional 6 months.

Additional file 1: Supplementary materials. Full Questionnaire in English version.

Background Situational factors during a fall among three common types of fractures of the distal forearm, hip, and vertebrae among older women in Taiwan were investigated. Methods In 2016 ~ 2017, study participants were identified from those aged ≥65 years who visited emergency departments due to a fall in two university-affiliated hospitals in Taipei. In addition to individual characteristics, situational factors during the fall (location, activity, change of center of mass, fall mode, fall direction, initiating a protective response, and being hit) were collected. A sample of 203 distal-forearm fractures, 189 vertebral fractures, and 375 hip fractures was recruited, while 717 women with a soft-tissue injury were used as a control group. The identification of situational risk factors for each type of fracture was validated by using those who sustained one of the other two types of fracture as a control group. Results After adjusting for age and other individual characteristics, compared to soft-tissue injuries, distal-forearm fractures were significantly more likely to occur with slips (odds ratio [OR] = 11.0; 95% confidence interval [CI] = 4.76 ~ 25.4), trips (OR = 3.40; 95% CI = 1.42 ~ 8.17), step-downs (OR = 4.95; 95% CI = 2.15 ~ 11.4), and from sideways falls (OR = 1.73; 95% CI = 1.12 ~ 2.67) and significantly less likely to occur indoors (OR = 0.62; 95% CI = 0.42 ~ 0.90) or from backwards falls (OR = 0.62; 95% CI = 0.41 ~ 0.95). Hip fractures were significantly more likely to occur with step-downs (OR = 1.76; 95% CI = 1.13 ~ 2.75) and from backwards (OR = 3.16; 95% CI = 2.15 ~ 4.64) or sideways falls (OR = 5.56; 95% CI = 3.67 ~ 8.41) and significantly less likely when hitting an object (OR = 0.26; 95% CI = 0.13 ~ 0.52) or initiating a protective response (OR = 0.58; 95% CI = 0.36 ~ 0.93). Vertebral fractures were significantly more likely to occur with slips (OR = 2.42; 95% CI = 1.30 ~ 4.50), step-downs (OR = 2.53; 95% CI = 1.43 ~ 4.48), and backwards falls (OR = 2.15; 95% CI = 1.39 ~ 3.32). Similar results were found in the validation analyses. Conclusions Large variations in situational risk factors for the three types of fracture in older women existed. A combination of individual and situational risk factors may display a more-comprehensive risk profile for the three types of fracture, and an intervention that adds training programs on safe landing strategies and effective compensatory reactions may be valuable in preventing serious injuries due to a fall.

Situational factors might help explain why most vertebral fractures occur in older people without a previous osteoporosis diagnosis. After adjusting for predisposing risk factors, the activity before the fall, type of fall, and falling direction remained as strong determinants of fall-related vertebral fractures in older men and women. A matched case-control study was conducted to investigate the effects of situational factors, in addition to predisposing factors, on clinical vertebral fractures in older men and women in Taiwan. Cases were community-dwelling individuals aged ≥ 65 years who visited emergency departments (EDs) of two university-affiliated hospitals due to a fall and had a primary diagnosis of a vertebral fracture during a 1-year period in 2017. Five control patients per case, matched by the time of falling, gender, and age, who sought care in the same ED due to a fall resulting in a soft tissue injury were selected. A total of 64 men (age range: 65 ~ 99 years) and 194 women (age range: 65 ~ 100 years), diagnosed with a vertebral fracture, participated in the study. Multivariable logistic models were conducted separately for men and women. Results suggested that the following factors were significantly associated with an increased risk of vertebral fractures in men: a low educational level (adjusted odds ratio [OR] = 1.95; 95% confidence interval (CI), 1.02 ~ 3.71), asthma (OR = 2.96; 95% CI, 1.35 ~ 6.92), depression (OR = 4.31; 95% CI, 1.03 ~ 17.5), toileting (OR = 2.30; 95% CI, 1.04 ~ 4.94), slipping (OR = 5.27; 95% CI, 1.80 ~ 15.4), stepping down (OR = 3.99; 95% CI, 1.40 ~ 11.4), sudden leg weakness (OR = 3.73; 95% CI, 1.13 ~ 12.4), and falling backwards (OR = 3.78; 95% CI, 1.83 ~ 7.80); and in women: a fracture history (OR = 2.00; 95% CI, 1.07 ~ 3.76), osteoporosis (OR = 1.94; 95% CI, 1.15 ~ 3.49), getting in/out of the bed/chair (OR = 1.90; 95% CI, 1.07 ~ 3.39), stepping down (OR = 2.10; 95% CI, 1.17 ~ 3.77), and falling backwards (OR = 4.00; 95% CI, 2.39 ~ 6.68) and sideways (OR = 2.61; 95% CI, 1.38 ~ 4.96). The combination of predisposing and situational risk factors may display a more comprehensive risk profile for the occurrence of VFs, and thus, interventions that add both types of risk factors may result in greater risk reduction of VFs, although those specifically targeted at situational risk factors during falls are limited and their effectiveness and efficiency remained to be explored.

We prospectively investigated the psychometric properties of the Quality of Life after Brain Injury (QOLIBRI) instrument among older patients with traumatic brain injury (TBI). The 37-item QOLIBRI comprises six domains (cognition, self, daily life and autonomy, social relationships, emotions, and physical problems). We recruited 333 patients ≥60 years of age with TBI from the neurosurgery clinics and emergency departments of three hospitals in Taipei, Taiwan. The ceiling and floor values for most QOLIBRI domains were

Objectives To compare the effects of guided home-based tai chi chuan (TCC) and lower extremity training (LET) and of levels of self-practice on falls and functional outcomes in older fallers. Design Randomized controlled trial. Setting Taipei, Taiwan. Participants Individuals aged 60 and older who had fall-related emergency department visits at least 6 months before participating in the study and ambulated independently at baseline (N = 456). Intervention Six months of TCC or LET. Measurements Four types of fall measures (falls, time to first fall, fallers, recurrent fallers) and six functional measures (handgrip strength, balance, mobility, fear of falling, depression, cognitive function). Results The TCC group was significantly less likely than the LET group to experience any falls during the 6-month intervention (incidence rate ratio (IRR) = 0.30, 95% confidence interval (CI) = 0.15–0.60), and the effects remained significant after 12 months of follow-up (IRR = 0.32, 95% CI = 0.14–0.71). These effects remained significant for injurious falls during the 6-month intervention (IRR = 0.33, 95% CI = 0.16–0.68) and the entire 18-month study (IRR = 0.39, 95% CI = 0.18–0.83). Similar results were obtained when another two fall measures (time to first fall, number of fallers) were used. Moreover, participants who independently practiced TCC or LET seven times per week or more were significantly less likely to experience injurious falls during the 6-month intervention (IRR = 0.41, 95% CI = 0.20–0.83) and the 18-month study (IRR = 0.43, 95% CI = 0.21–0.87) than their counterparts, had a significantly longer time to first injurious fall, and were significantly less likely to have an injurious fall during the 6-month intervention. Cognitive function improved to a greater extent in the TCC group than in the LET group over the 18-month study. Conclusion Home-based TCC may reduce the incidence of falls and injurious falls more than conventional LET in older fallers, and the effects may last for at least 1 year.

Objective To examine the level of agreement between patients and their proxies on a measure of health-related quality of life (HRQL) 1 year after traumatic brain injury (TBI). Design A cross-sectional study. Setting Four hospitals in Taipei. Participants Participants (N=176) were patients with TBI (n=88) identified from discharge records of 4 hospitals in Taiwan and family members or friends (n=88) who could answer questions regarding the patient's health and HRQL 1 year after the injury. Interventions Not applicable. Main Outcome Measures A health profile of the brief Taiwanese version of the World Health Organization Quality of Life (WHOQOL-BREF) and 2 health utility measures of the time tradeoff (TTO) and standard gamble (SG). Results Compared with proxy responses, patients provided higher ratings on the domains of the WHOQOL-BREF and lower ratings on the TTO and SG. Intraclass correlation coefficients between patient and proxy ratings varied among the 4 domains of the WHOQOL-BREF, in which levels of agreement were moderate or good for physical capacity (.69) and low for psychological well-being (.45), social relationships (.24), and the environment (.32). Levels of agreement were extremely low for the TTO (0.0) and SG (.10). A profile analysis showed that patients' ratings on the WHOQOL-BREF, on average, were significantly greater than those of their proxies (mean difference, 3.07), with a similar distribution of scatter responses (mean difference, .002) and shape agreement (mean difference, .57). Greater variations in the patient-proxy level of agreement appeared in patients who were younger and had more severe injuries, and also with parent and child proxies. Conclusions To assess the HRQL of patients with a TBI, the level of patient-proxy agreement was adequate for the physical domain but was lower for the social and environmental domains, and the agreement was very low for the TTO and SG. Furthermore, a patient's age and injury severity, and the patient-proxy' relationship may affect the agreement.

AIM: A nested case-control study was carried out to examine relationships of a fall-risk score and the use of single medications and polypharmacy with falls among hospitalized patients aged 50 years and older in Taiwan. METHODS: There were 83 patients who experienced a fall during hospitalization in an acute-care hospital. Matched by age and sex, five control patients for each case were randomly selected from all other inpatients who had not experienced any fall at the time of the index fall. RESULTS: Patients who took tricyclic antidepressants, diuretics, and narcotics were 3.36-, 1.83- and 2.09-fold, respectively, more likely to experience a fall than their counterparts. Conversely, patients who took beta-blockers were 0.34-fold more likely than those who did not take them to experience a fall. Patients taking ≥6 medications were 3.08-fold more likely than those taking fewer medications to experience a fall, whereas those with anxiety were 4.72-fold more likely to experience a fall than those without. A high fall-risk score was not significantly associated with the occurrence of falls. CONCLUSIONS: Among older hospitalized patients, tricyclic antidepressants, diuretics, narcotics, and polypharmacy should be mindfully prescribed and reviewed on a regular basis. A fall-risk scale developed from community-dwelling older people might not accurately predict falls in hospitalized patients. Further research to validate the negative effect of beta-blocker use on falls is required. Geriatr Gerontol Int 2014; ●●: ●●-●●. Language: en

There were differences in risk factors between men and women and between two follow-up time lengths. Osteoporosis was significantly associated with recurrent falls for women but not for men. The relationship of osteoporosis with falls in the past year decreased during follow-up, while those of sedatives and hypnotics remained.A prospective study to investigate relationships between osteoporosis and recurrent falls at two follow-up lengths of 6 and 12 months in older men and women.In total, 204 men and 447 women who visited an emergency department due to a fall were recruited.For men, the risk of falling was not significantly associated with osteoporosis at 6 or 12 months. Men with a fall history were 127 and 100 %, respectively, more likely to have a fall at 6 and 12 months than those without. Men who did not use walking aids were 97 % more likely to have a fall at 12 months than those who did. Women with osteoporosis were 246 and 104 %, respectively, more likely to have a fall at 6 and 12 months than those without. Women with a fall history were 129 and 66 %, respectively, more likely to have a fall at 6 and 12 months than those without. Women taking sedatives and hypnotics were 75 and 102 %, respectively, more likely to have a fall at 6 and 12 months than their counterparts. Women with depression were 138 % more likely to have a fall at 6 months and those using walking aids were 59 % more likely to have a fall at 12 months, compared to their counterparts.Osteoporosis is association with falls for older women but not for older men. Identifying risk factors for recurrent falls in older people may be affected by the follow-up length, as their associations are reduced over time.

A longitudinal study was conducted to investigate the effects of injury type and discharge placement on mortality, falls, hospital admissions, and changes in activities of daily living (ADLs) over a 12-month period among older fallers. Of 762 community-dwelling people aged 65 years or older who visited an emergency department (ED) of a general hospital in Taiwan due to a fall, 273 sustained a hip fracture, 157 had a vertebral fracture, 47 had a distal forearm fracture, 102 had a traumatic brain injury, and 183 had soft-tissue injuries. Results showed that, compared to patients with a soft-tissue injury, those with TBI had significantly higher risks of dying (rate ratio (RR) = 3.59) and hospital admissions (RR = 3.23) and better improvement in ADLs (1.93 points) at 6 months post-injury, and those who sustained a hip fracture (4.26 and 4.41 points), a vertebral fracture (3.81 and 3.83 points), or a distal-forearm fracture (2.80 and 2.80 points) had significantly better improvement in ADLs at 6 and 12 months post-injury. Patients discharged to a nursing home had a significantly increased risk of death (RR = 2.08) and hospital admission (RR = 2.05) than those returning to their usual residence during the first year post-injury. No significant differences in the occurrence of falls during the first post-injury year were found among patients with different injury types or between those with different discharge placements. In conclusion, among the five major fall injury types in older people, TBIs result in the highest risk of death and hospital admissions, while hip and vertebral fractures exhibited the largest improvement during the first year after injury. Additionally, nursing home care may be associated with increased risks of death and hospital admissions than home care. In addition to primary prevention of falls, further research to investigate mechanisms leading to TBIs during a fall is needed to facilitate effective secondary fall-prevention programs for older people.

A prospective study was conducted to compare criterion, predictive, and construct validities of 9 fracture/osteoporosis assessment tools, including calcaneal quantitative ultrasonography (QUS), Age Bulk One or Never Estrogens (ABONE), body weight criterion (BWC), Fracture Risk Assessment Tool (FRAX), Garvan fracture risk calculator (GARVAN), Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Index of Risk (OSIRIS), Osteoporosis Self-Assessment Tool for Asians (OSTA), and Simple Calculated Osteoporosis Risk Estimation (SCORE), among older men and women in Taiwan. Using the femoral neck dual-energy x-ray absorptiometry (DXA) T-score as an external criterion, the sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and the area under the receiver operating characteristic curve (AUC) for each tool were calculated. The ability of these tools to predict injurious falls was examined. A principal component analysis was applied to understand whether these tools were measuring the same underlying construct. The FRAX, BWC, ORAI, OSIRIS, OSTA, and SCORE had AUCs of ≥0.8 in men, while the GARVAN, OSIRIS, OSTA, and SCORE had AUCs of ≥0.8 in women. The sensitivity, negative predictive value, and likelihood ratio of the ABONE, BWC, ORAI, OSIRIS, OSTA, and SCORE tools in both men and women were 100%, ≥90%, and 0.0, respectively; the specificity and positive predictive value and likelihood ratio were far from satisfactory. The GARVAN displayed the best predictive ability of a fall in both men (AUCs, 0.653–0.686) and women (AUCs, 0.560–0.567), despite being smaller in women. The 9 screening tools and 2 central DXA measurements assessed 5 different factors, while the ABONE, BWC, ORAI, OSIRIS, OSTA, and SCORE measured the same one. Simple self-assessment tools can serve as initial screening instruments to rule out persons who have osteoporosis; however, these tools may measure a different construct other than fracture/osteoporosis risk.

Chiu M-H, Hwang H-F, Lee H-D, Chien D-K, Chen C-Y, Lin M-R. Effect of fracture type on health-related quality of life among older women in Taiwan. Objective To investigate changes in health-related quality of life (HRQOL) during the first year after injury in elderly Taiwanese women who had fractured a hip, vertebra, distal forearm, or multiple sites. Design Longitudinal cohort study. Setting Personal or telephone interviews of patients from 3 teaching hospitals. Participants Women (N=347; mean age ± SD, 78.0±6.6y) who had sustained a fracture of the hip, vertebra, or distal forearm due to a fall participated in the baseline assessment, in which both current and prefracture HRQOL data were collected. At 6 and 12 months after the fracture, 285 and 254 women, respectively, completed the follow-up assessments. Interventions Not applicable. Main Outcome Measure The 4 domains of physical capacity, psychological well-being, social relationships, and environment of the brief version of the World Health Organization Quality of Life questionnaire were assessed. Results After adjusting for prefracture HRQOL scores and baseline characteristics, women with a hip fracture showed a significant improvement in physical capacity (3.5 points) and a significant decline in social relationships (−3.7 points). Relative to women with a hip fracture at 12 months after injury, those with a vertebral fracture exhibited significantly greater improvement (5.2 points) in physical capacity; those with a distal forearm fracture had significantly greater improvements in physical capacity (11.5 points), psychological well-being (8.4 points), social relationships (7.2 points), and environment (10.9 points), while those with multiple fractures displayed significantly greater improvement in physical capacity (16.5 points), psychological well-being (13.3 points), and environment (10.3 points). Conclusions Among the 4 fracture types in elderly women, hip fractures may result in the smallest improvement in the physical domain and the greatest declines in the psychological, social, and environmental domains during the first year. The magnitude of the impact of each fracture type varied across different domains.

Objective. This study examined criterion, convergent, and discriminant validities of quantitative ultrasound (QUS) for identifying low bone density among people aged 55 years and older in Taiwan. Methods. We recruited 453 community-dwelling volunteers and 30 patients with lower extremity fractures. Bone density was assessed using both calcaneal QUS and femoral neck dual-energy x-ray absorptiometry (DXA). Two QUS parameters, speed of sound (SOS) and broadband ultrasound attenuation (BUA), were also used to estimate heel bone mineral density (HBMD). Results. Using DXA as the criterion for identifying low bone density (DXA T score of 1.0 or lower), likelihood ratios for BUA and SOS at the 50th percentile and HBMD for men were 1.50, 1.75, and 1.28, respectively; the counterparts for women were 1.54, 2.13, and 1.29. As for identifying osteoporosis (DXA T score of –2.5 or lower), higher likelihood ratios of the 3 QUS parameters were gained. For convergent validity, Pearson correlation coefficients for DXA with BUA, SOS, and HBMD ranged from 0.40 to 0.43 for men and from 0.48 to 0.53 for women. For the ability to discriminate men and women with lower extremity fractures from those without, no significant differences in the area under the receiver operating characteristic curve were detected between BUA, SOS, and HBMD and DXA after adjusting for age, body mass index, fall history, and current smoking. Conclusions. Although having very good convergent and discriminant validities and fair criterion validity, calcaneal QUS may be a screening tool for identifying low bone density. Key words: dual-energy x-ray absorptiometry; older people; osteoporosis; quantitative ultrasound; screening; Taiwan.

Lin M-R, Hwang H-F, Yu W-Y, Chen C-Y. A prospective study of factors influencing return to work after traumatic spinal cord injury in Taiwan. Objective To examine comprehensively the effects of physical, psychologic, and sociologic characteristics on employment among persons after a traumatic spinal cord injury (SCI) in Taiwan. Design A prospective study with follow-up telephone interviews over a 3-year period. Setting To register people who had sustained an SCI, medical records of 4 hospitals were reviewed using codes of the International Classification of Diseases–9th Revision–Clinical Modifications from 806.0 to 806.9 and from 952.0 to 952.9. Participants Subjects (N=219) employed at the time of injury. Interventions Not applicable. Main Outcome Measures Employment status after an SCI. Results The employment rate was 32.9%. After controlling for other variables, education level (relative rate [RR]=4.01∼8.17), autonomy in transportation (RR=5.13), professional licensure (RR=1.86), and thrill and adventure-seeking trait (RR=1.12) were positively and significantly associated with employment, while subjects with more severe overall injury severity (RR=0.95), preinjury chronic conditions (RR=0.20), necessity for aids for daily living (RR=0.31), and depression (RR=0.38) were less likely to have been employed than their counterparts. Conclusions In addition to education level and traditional physical factors, overall injury severity and psychologic factors such as thrill and adventure seeking and depression can also influence the return to work after an SCI.

OBJECTIVES: To compare the effects of three fall-prevention programs (education (ED), home safety assessment and modification (HSAM), and exercise training (ET)) on quality of life (QOL), functional balance and gait, activities of daily living (ADLs), fear of falling, and depression in adults aged 65 and older. DESIGN: A 4-month randomized trial. SETTING: Randomized, controlled trial. PARTICIPANTS: One hundred fifty participants who had experienced a recent fall. MEASUREMENTS: QOL was assessed according to the brief version of the World Health Organization Quality of Life instrument (WHOQOL-BREF), functional balance and gait according to functional reach and Tinetti balance and gait, ADLs according to the Older Americans Resources and Services questionnaire, fear of falling according to a visual analog scale, and depression level according to the Geriatric Depression Scale. RESULTS: The score changes for the ET group were 2.1 points greater on the physical domain (95% confidence interval (CI)=-1.2-5.3), 3.8 points greater on the psychological domain (95% CI=0.7-7.0), and for the WHOQOL-BREF, 3.4 points greater on the social domain (95% CI=0.7-6.1) and 3.2 points greater on the environmental domain (95% CI=0.6-5.7) than for the ED group. The score change for each domain of the WHOQOL-BREF for the HSAM group was greater than that for the ED group, although these results were not statistically significant. The ET group also had greater improvements in functional reach, Tinetti balance and gait, and fear of falling than the ED group. CONCLUSION: The QOL outcome supports the superiority of ET over the other two interventions in older people who have recently fallen. This finding also parallels those gathered from the functional measures. Language: en

This study compared the ability of five injury severity measures, namely the Abbreviated Injury Scale to the Head (AIS-H), Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), Extended Glasgow Outcome Scale (GOSE), and Injury Severity Score (ISS), to predict return-to-work after a traumatic brain injury (TBI). Furthermore, factors potentially associated with return-to-work were investigated. In total, 207 individuals aged ≤65 years newly diagnosed with a TBI and employed at the time of injury were recruited and followed-up for 1year by telephone every 3 months. A bivariate proportional hazards model analysis revealed that all five injury severity measures were significantly associated with return-to-work after a TBI. The AIS-H and non-head ISS explained 23.8% of the variation in the duration of returning to work from discharge after hospitalization for a TBI; similarly, the GCS, GOS, GOSE, and ISS respectively accounted for 4.7%, 21.4%, 12.9%, and 48.4% of the variation. A multivariable analysis revealed that individuals with higher injury severity as measured by the ISS (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.92-0.97), a lack of autonomy in transportation (HR, 2.55; 95% CI, 1.23-5.32), cognitive impairment (HR, 0.47; 95% CI, 0.28-0.79), and depression (HR, 0.97; 95% CI, 0.95-0.99) were significantly less likely to be employed after a TBI. In conclusion, of the five injury severity measures, the ISS may be the most capable measure of predicting return-to-work after a TBI. In addition to injury severity, autonomy in transportation, cognitive function, and the depressive status may also influence the employment status during the first year after a TBI.

The traditional "teacher-centered" instruction model is still currently pervasive in nursing education. However, this model does not stimulate the critical thinking or foster the self-learning competence of students. In recent years, the rapid development of information technology and the changes in educational philosophy have encouraged the development of the "flipped classroom" concept. This concept completely subverts the traditional instruction model by allowing students to access and use related learning activities prior to class on their smartphones or tablet computers. Implementation of this concept has been demonstrated to facilitate greater classroom interaction between teachers and students, to stimulate student thinking, to guide problem solving, and to encourage cooperative learning and knowledge utilization in order to achieve the ideal of student-centered education. This student-centered model of instruction coincides with the philosophy of nursing education and may foster the professional competence of nursing students. The flipped classroom is already an international trend, and certain domestic education sectors have adopted and applied this concept as well. However, this concept has only just begun to make its mark on nursing education. This article describes the concept of the flipped classroom, the implementation myth, the current experience with implementing this concept in international healthcare education, and the challenging issues. We hope to provide a reference for future nursing education administrators who are responsible to implement flipped classroom teaching strategies in Taiwan.翻轉教室—資訊科技融入護理教育的新教學策略.目前護理教育仍以「教師為中心」的傳統講授的教學模式，無法激發學生的批判性思考及培養自主學習的能力。近年來隨著資訊科技快速發展及教育理念變遷，發展出「翻轉教室」的概念及教學模式，它完全顛覆傳統的教學模式，讓e世代學生透過智慧型手機或平板電腦等資通訊科技工具在課前進行相關學習活動，課堂中增進老師與學生互動機會，藉以激發學生思考、引導解決問題，鼓勵合作學習及活用知識，落實以學生為中心的教育理念，此種以學生為中心的教學模式與護理教育理念及培育學生的專業能力不謀而合。在國際間翻轉教室蔚為潮流之際，國內各領域教育界也開始推動翻轉教室的教學模式，然而翻轉教室不論在國內外護理教育尚在萌芽階段，因此本文說明翻轉教室的概念及推展產生的迷思、國際間醫護教育應用翻轉教室的經驗及面臨議題，以做為國內護理教育未來推動翻轉教室教學策略的參考。.

This study examined psychometric properties of a brief version of the World Health Organization Quality of Life questionnaire (WHOQOL-BREF) among persons with traumatic brain injury (TBI) and the relations of the WHOQOL-BREF domains, including physical capacity, psychological wellbeing, social relationships, and environment, to different indicators of TBI severity. Of the 354 eligible and available subjects from 22 hospitals in northern Taiwan over a 6-month period, 199 completed telephone interviews during data collection. Three indicators of TBI severity were used: the Glasgow Coma Scale, the presence of post-traumatic amnesia, and the abbreviated injury scale to the head. All domain scores of the WHOQOL-BREF had nearly symmetrical distributions: low percentages of ceiling and floor values (0-3%), low missing rates (0-0.5%) for all but one item (43.2%), and very good internal consistency (0.75-0.89) and test-retest reliability (0.74-0.95). The WHOQOL-BREF also exhibited excellent known-groups validity, as well as very good responsiveness and convergent validity with regard to employment, independence in daily life activities, social support, and depression. After adjustment for potential confounders, almost none of the domain scores of the WHOQOL-BREF significantly differed in the severity levels of the three severity indicators. In conclusion, the WHOQOL-BREF is an appropriate health-related quality of life (HRQL) instrument for persons with TBI. Furthermore, the initial severity of the TBI might not be suitable for predicting levels of HRQL in persons with TBI.

Background and Purpose. The rating scale (RS), standard gamble (SG), and time trade-off (TTO) for people with traumatic spinal cord injuries (SCIs) have not been reported. This study compared psychometric performances of these preference-based measures among people with SCIs in Taiwan. Subjects and Methods. In total, 187 subjects from a nationwide registry of people with traumatic SCIs were interviewed by telephone. Score distributions, interrater reliability, discriminant ability, and convergent validity for the RS, SG, and TTO were compared. Results. The mean (median) values of the RS, SG, and TTO were 0.67 (0.70), 0.64 (0.75), and 0.53 (0.50), respectively, and their corresponding intraclass correlation coefficients for intrarater and interrater test-retest reliability were .92 and .89, .78 and .73, and .91 and .78. Compared with the SG and TTO, the RS had fewer floor and ceiling values as well as percent changes, more missing observations, a larger effect size, and better discrimination ability. The results of Spearman correlation and factor analysis showed that the SG strongly converged with the TTO (r=.65, and in a single common factor), but they weakly converged with the RS (r=.33 with the SG and r=.27 with the TTO). In the linear regression models, the RS was significantly associated with neurological severity, employment, educational level, and self-care ability; the SG was associated with neurological severity and employment; and the TTO was associated only with neurological severity. Discussion and Conclusion. The RS generally performed better than the SG and TTO among people with traumatic SCIs; however, the underlying construct measured by the RS differed considerably from those measured by the SG and TTO. [Lin MR, Hwang HF, Chung KP, et al. Rating scale, standard gamble, and time trade-off for people with traumatic spinal cord injuries.

OBJECTIVES: To compare the practicality, reliability, validity, and responsiveness of the timed up and go (TUG), one-leg stand (OLS), functional reach (FR), and Tinetti balance (TB) performance measures in people aged 65 and older. DESIGN: A prospective study. SETTING: Shin-Sher Township of Taichung County, westcentral Taiwan. PARTICIPANTS: Twelve hundred community-dwelling older people. MEASUREMENTS: During an initial assessment at their residences, participants were interviewed for demographics, cognition, fall history, use of a walking aid, and activities of daily living (ADLs), in addition to completing the four balance tests. Falls were ascertained by telephone every 3 months for a 1-year follow-up; the four balance measures and ADLs were also reassessed at the end of the follow-up year. RESULTS: Of the four balance measures, the OLS had the lowest participation rate, and participation of people who were cognitively impaired had fallen in the previous year, used a walking aid, or suffered from an ADL disability was lower than for their counterparts. The time to complete the tests ranged from 58 seconds for OLS, to 160 seconds for the TB. All four balance measures exhibited excellent testretest reliability and discriminant validity but poor responsiveness to fall status. The TB showed better discriminant, convergent, and predictive validities and responsiveness to ADL changes than the other three tests. CONCLUSION: According to psychometric properties, the most suitable performance measure for evaluating balance in community-dwelling older people was the TB, followed by the TUG. J Am Geriatr Soc 52:1343–1348, 2004.

A 20-month prospective study was conducted to investigate the effect of motorcycle crash experience on changes in risk taking among 2514 urban and 2304 rural students in Taiwan. Risk taking was assessed using a 14-item self-administered questionnaire at the beginning and end of the study. A risk-taking score for each student at the initial and the last follow-up assessments was generated from adding up points across all 14 items. For exposure variables, the study documented past motorcycle crash history at the initial assessment and collected detailed information about any motorcycle crash involvement that occurred during the study period. A general linear mixed model was applied to assess the effects of prior and recent crash involvements on the path of risk-taking behavior. The results show that at the initial assessment, students with crash experience had higher risk-taking levels than those without crash experience. However, crash experience, irregardless of whether it was measured in terms of crash history prior to the study, crash frequency, time elapsed since the last crash, or crash severity, did not significantly change the risk-taking path among students, even though its effect differed between urban and rural areas.

A case-control study was conducted to determine the relationship between motorcycle helmets, including type (i.e. partial or full coverage) and fastening status (i.e. loose or firm), and cervical spinal cord injuries (SCIs) in Taiwan. Based on a nationwide registry consisting of 396 motorcycle riders with traumatic SCIs during the 4-year period from July 1992 to June 1996, 229 subjects injured at cervical levels were defined as cases and 167 injured at other spinal levels as controls. Furthermore, additional information on the type and fastening status of the helmet was collected by telephone interview, and 147 subjects, including 79 with cervical and 68 with noncervical lesions, responded. Results of the logistic regression model show that neither different helmet types nor fastening status increased the occurrence of cervical SCIs when motorcycle riders were involved in severe crashes.

Background: while life expectancy among older people has been lengthened due to improved public health and medical interventions, the importance of health-related quality of life in later life has also increased. However, the application of a generic health-related quality of life measure for older people needs to be carefully validated. Objective: to evaluate the practicality, reliability, validity, and responsiveness of the use of the brief version of the World Health Organization Quality of Life for people aged 65 years or older. Design: a prospective study. Methods: for a baseline assessment, 1200 community-dwelling older people living in Shin-Sher Township of Taichung County, Taiwan, completed the brief version of World Health Organization Quality of Life at their residences either by themselves or with the assistance of an interviewer. Furthermore, score changes in each health-related quality of life domain after a fall were followed up for assessing its responsiveness. Results: the average length of time required to complete the questionnaire was short (10.6 minutes for self-administration and 15.3 minutes for personal interview), and the score distribution in each domain was symmetrical with no Xoor or ceiling effect. Furthermore, all domain scores indicated excellent discriminant validity, construct validity, and responsiveness as well as good internal consistency and intra- and inter-observer test-retest reliabilities. Nevertheless, two items related to work capacity and sexual activity had higher missing values (4.5% and 16.5%) and poor interobserver test-retest reliabilities (0.43 and 0.20). Suggested modiWcations to the two items for older people are discussed. Conclusion: with a few modiWcations, the brief World Health Organization Quality of Life is a suitable health-related quality of life instrument for older people.

OBJECTIVE:: To identify risk factors for traumatic brain injuries (TBIs) during falls in older Taiwanese people. PARTICIPANTS:: Case patients consisted of 113 patients aged 60 years or older with a moderate/severe TBI due to a fall. Two control groups: (1) 339 older patients with a soft-tissue injury; and (2) 113 with a mild-TBI due to a fall. Proxies were required to provide information for a considerable number of patients. DESIGN:: Matched case-control study. SETTINGS:: The emergency departments of 3 general hospitals. MEASURES:: Sociodemographic, lifestyle behavior, chronic condition, medication use, functional abilities, and fall-related characteristics. RESULTS:: When patients with a soft-tissue injury were assigned to the control group, men were 2.06-fold more likely to have a moderate/severe TBI than women. Subjects who took antiarrhythmics within 4 hours of a fall were 2.59-fold more likely to have a moderate/severe TBI than those who took none. Subjects who were negotiating stairs and getting in/out of the bed/chair were 3.12-fold and 2.97-fold, respectively, more likely to have a moderate/severe TBI than those who fell while walking. Falling backward and sideways was 4.07-fold and 2.30-fold, respectively, more likely to cause a moderate/severe TBI than falling forward. When patients with a mild-TBI were assigned to the control group, results were similar, with the exception that the effect of antiarrhythmic use became nonsignificant and subjects who took 2 or more medications were 3.07-fold more likely to have a moderate/severe TBI than those who took none. CONCLUSION:: Avoiding a head impact during a backward or sideways fall, reducing unnecessary use of polypharmacy and antiarrhythmics, and maintaining safety during stair negotiation and bed/chair transfer may protect an elderly person from a severe brain injury. Language: en

This paper examines the impact of the Chi-Chi earthquake, which hit central Taiwan on September 21, 1999, on the quality of life among the elderly survivors. The 28-item Taiwanese-adapted brief version of the World Health Organization's quality of life questionnaire (WHOQOL-BREF) was used to measure quality of life in four domains: physical capacity, psychological well-being, social relationships, and environment. These measures were coincidently collected in a separate study from 368 subjects aged 65 and older in the affected area shortly before the earthquake. Of these subjects, 268 were interviewed in a follow-up assessment 12 months after the earthquake. Linear mixed models were applied to investigate how quality of life in each of the four domains changed from the pre-earthquake assessment to 12 months after the earthquake, and how these changes depended on the level of damage to residences. In conclusion, elderly survivors tended to report lower quality of life in physical capacity, psychological well-being, and environment 12 months after the earthquake than at the assessment prior to the earthquake, regardless of the level of damage to their residences during the earthquake. However, those whose residences completely collapsed during the earthquake reported a higher quality of life in social relationships while others reported the opposite.

A nested case-control study was carried out to examine relationships of a fall-risk score and the use of single medications and polypharmacy with falls among hospitalized patients aged 50 years and older in Taiwan.There were 83 patients who experienced a fall during hospitalization in an acute-care hospital. Matched by age and sex, five control patients for each case were randomly selected from all other inpatients who had not experienced any fall at the time of the index fall.Patients who took tricyclic antidepressants, diuretics, and narcotics were 3.36-, 1.83- and 2.09-fold, respectively, more likely to experience a fall than their counterparts. Conversely, patients who took beta-blockers were 0.34-fold more likely than those who did not take them to experience a fall. Patients taking ≥6 medications were 3.08-fold more likely than those taking fewer medications to experience a fall, whereas those with anxiety were 4.72-fold more likely to experience a fall than those without. A high fall-risk score was not significantly associated with the occurrence of falls.Among older hospitalized patients, tricyclic antidepressants, diuretics, narcotics, and polypharmacy should be mindfully prescribed and reviewed on a regular basis. A fall-risk scale developed from community-dwelling older people might not accurately predict falls in hospitalized patients. Further research to validate the negative effect of beta-blocker use on falls is required.

Three modifiable factors of fall direction, poor bone strength, and depression were associated with an increased risk of hip fractures for elderly men and women; fall direction was a much stronger predictor than the other two. When a fall occurs, changing fall direction may be most effective to prevent hip fractures.A matched case-control study was conducted to identify risk factors for hip fractures in elderly men and women in Taiwan.Cases were defined as persons who visited the emergency room due to a fall and were diagnosed with a first hip fracture. For each case, a control was matched by gender and time of falling, selected from persons who sought care at the same emergency room due to a fall resulting in injury other than a hip fracture. In total, 85 paired men and 221 paired women were included.For men, backward, straight-down, and sideways falls were associated with 10.8-, 13.6-, and 15.2-fold increased risks of hip fractures, respectively, compared with forward falls. Poor bone strength and depression were associated with 2.27- and 2.85-fold increased risks of hip fractures, respectively, while dependence in ≥3 activities of daily living was associated with a fivefold lower risk. For women, compared with forward falls, backward, straight-down, and sideways falls were associated with 10.2-, 9.86-, and 12.8-fold increased risks of hip fractures, respectively. Living in a rented house, poor bone strength, depression, and use of antidiabetics were associated with 1.65-, 2.78-, 1.89-, and 1.92-fold increased risks of hip fractures, respectively. Hormone replacement therapy was associated with a fivefold lower risk of hip fractures.While bone strength and depression can be risk factors for hip fractures in elderly people, the direction of the fall was the strongest predictor. Some risk factors differed between elderly men and women.

To compare the effects of three fall-prevention programs (education (ED), home safety assessment and modification (HSAM), and exercise training (ET)) on quality of life (QOL), functional balance and gait, activities of daily living (ADLs), fear of falling, and depression in adults aged 65 and older.A 4-month randomized trial.Randomized, controlled trial.One hundred fifty participants who had experienced a recent fall.QOL was assessed according to the brief version of the World Health Organization Quality of Life instrument (WHOQOL-BREF), functional balance and gait according to functional reach and Tinetti balance and gait, ADLs according to the Older Americans Resources and Services questionnaire, fear of falling according to a visual analog scale, and depression level according to the Geriatric Depression Scale.The score changes for the ET group were 2.1 points greater on the physical domain (95% confidence interval (CI)=-1.2-5.3), 3.8 points greater on the psychological domain (95% CI=0.7-7.0), and for the WHOQOL-BREF, 3.4 points greater on the social domain (95% CI=0.7-6.1) and 3.2 points greater on the environmental domain (95% CI=0.6-5.7) than for the ED group. The score change for each domain of the WHOQOL-BREF for the HSAM group was greater than that for the ED group, although these results were not statistically significant. The ET group also had greater improvements in functional reach, Tinetti balance and gait, and fear of falling than the ED group.The QOL outcome supports the superiority of ET over the other two interventions in older people who have recently fallen. This finding also parallels those gathered from the functional measures.

This study compared the psychometric performance of the brief form of the World Health Organization Quality of Life (WHOQOL-BREF) with the Short-Form 36 (SF-36) for people with traumatic spinal cord injuries in Taiwan.From a nationwide registry of traumatic spinal cord injuries, 187 subjects completed telephone interviews. Score distributions, internal consistency, intrainterviewer and interinterviewer test-retest reliabilities, convergent and known-groups validities, and the responsiveness between the WHOQOL-BREF (with an overall quality-of-life facet and four domains) and the SF-36 (with eight domains) were compared.Both the WHOQOL-BREF and the SF-36 exhibited low missing values (0.9-7.7 vs. 2.1-3.8), very good internal consistencies (Cronbach's alpha coefficients of 0.75-0.87 vs. 0.72-0.98), intrainterviewer reliabilities (intraclass correlation coefficients of 0.84-0.98 vs. 0.71-0.99) and responsive statistics (0.787-1.83 vs. 0-0.92), and fair interinterviewer reliabilities (intraclass correlation coefficients of 0.56-0.95 vs. 0.41-0.98), whereas the WHOQOL-BREF's domains converged with the conceptually related domains of the SF-36. Nonetheless, compared with the SF-36, the WHOQOL-BREF had lower percentages of ceiling (0.0%-0.4% vs. 0.4%-63.8%) and floor (0.0%-1.3% vs. 0.4%-28.1%) values and better known-groups validity and responsiveness.The WHOQOL-BREF is an appropriate generic health-related quality of life measure for persons with traumatic spinal cord injuries.

Background and Purpose. It is important to determine the effect of adherence to a tai chi program on falls and related functional outcomes in older people. This study examined the effect of a community-based tai chi program on injurious falls, balance, gait, and fear of falling among people aged 65 years and older in Taiwan. Subjects and Methods. In 6 rural villages in Taichung County, 1,200 subjects participated in the initial assessment. During a 1-year intervention period, all study villages were provided with education on fall prevention. Two villages had been provided tai chi exercise (n=472 participants or “tai chi villagers”), and 4 villages served as control villages (n=728 participants or “control villagers”). Injurious falls were ascertained by telephone interviews every 3 months over a 2-year study period; additionally, balance, gait, and fear of falling were assessed in 2 follow-up assessments. Results. Eighty-eight subjects, 83 from the tai chi villages and 5 from the control villages, participated and practiced in the tai chi program (the group labeled “tai chi practitioners”). After the tai chi program, injurious falls among the control villagers significantly declined by 44% (adjusted rate ratio [RR]=0.56; 95% confidence interval [CI]=0.36–0.92). Compared with the results for the control villagers, the decline was 31% greater (RR=0.69; 95% CI=0.30–1.56) among the tai chi villagers and 50% greater (RR=0.5; 95% CI=0.11–2.17) among the tai chi practitioners; the results did not reach statistical significance. Furthermore, compared with the scores for the control villagers, the scores for the tai chi practitioners increased by 1.8 points (95% CI=0.2–3.4) on the Tinetti Balance Scale and increased by 0.9 point (95% CI=0.1–1.8) on the Tinetti Gait Scale. No significant changes in the fear of falling were detected among the tai chi practitioners, tai chi villagers, and control villagers. Discussion and Conclusion. Tai chi can prevent a decline in functional balance and gait among older people. However, the reduction in injurious falls attained with tai chi did not reach statistical significance; the statistical inefficiency may have resulted partly from the large decline in injurious falls in control villagers. Finally, the unexpected effect of educational intervention on reducing injurious falls in different settings needs to be further examined. on injurious falls, balance, gait, and fear of falling in older people. Phys Ther. 2006;86:1189 –1201.]

STUDY OBJECTIVE: A cohort of 4,729 junior college students in Taiwan was studied to determine risk factors for increased severity of motorcycle injuries. METHODS: Crash characteristics were collected by using self-administered questionnaires soon after a student was involved in a motorcycle crash. The proportional odds model with generalized estimating equations, with correlated ordinal responses for collisions categorized into not injured, mildly injured, and severely injured categories, was used to determine the odds of injury severity. RESULTS: A total of 1,889 motorcycle crashes involving 1,284 persons occurred over a 20-month period from November 1994 to June 1996. There were 1,339 noninjuries, 474 mild injuries, and 76 severe injuries. The adjusted odds ratio (OR) of rural to urban roads having a greater level of injury severity was 1.64. Compared with noncollisions, collisions with a moving car (adjusted OR=1.76), a parked car (adjusted OR 1.90), or another stationary object (adjusted OR=2.31) increased the odds for a greater level of injury severity. Riders using Sanyang (adjusted OR=1.63) and Yamaha (adjusted OR=1.39) motorcycles had greater odds of being involved in a crash with a greater level of injury compared with those riding Kymco motorcycles. Darkness (adjusted OR=1.65) and greater speeds (adjusted OR=1.63 to 4.69) also increased the odds of greater injury severity. CONCLUSION: At the time of motorcycle crashes, factors such as being on rural roads, collisions with a heavier object, some motorcycle makes, darkness, and greater speeds increased the severity of motorcycle injuries among these young adult riders.

This paper examines the impact of the Chi-Chi earthquake, which hit central Taiwan on September 21, 1999, on the quality of life among the elderly survivors. The 28-item Taiwanese-adapted brief version of the World Health Organization's quality of life questionnaire (WHOQOL-BREF) was used to measure quality of life in four domains: physical capacity, psychological well-being, social relationships, and environment. These measures were coincidently collected in a separate study from 368 subjects aged 65 and older in the affected area shortly before the earthquake. Of these subjects, 268 were interviewed in a follow-up assessment 12 months after the earthquake. Linear mixed models were applied to investigate how quality of life in each of the four domains changed from the pre-earthquake assessment to 12 months after the earthquake, and how these changes depended on the level of damage to residences. In conclusion, elderly survivors tended to report lower quality of life in physical capacity, psychological well-being, and environment 12 months after the earthquake than at the assessment prior to the earthquake, regardless of the level of damage to their residences during the earthquake. However, those whose residences completely collapsed during the earthquake reported a higher quality of life in social relationships while others reported the opposite.